hernia of the umbilical cord [وضع التوافق] of the umbilical cord.pdf · umbilical cord...

Kingdom of Saudi Arabia, King Abdulaziz university, Jeddah

Hernia Of The Umbilical Cord

Dr. Mazen O. Kurdi (FRCSI)Ass. Prof. pediatric surgery

Prof. Dr. Yasir S. Jamal (FRCSI, FICS)f f d lProf. of pediatric & plastic surgery

President, Saudi association of ped. Surgeryd d f f lVice-president, Saudi scientific ass. of plastic surgeryHead, division of pediatric surgery

Umbilical cord hernia

Introduction:Introduction:It is a simple failure of complete It is a simple failure of complete return of the midgut to the peritonealreturn of the midgut to the peritonealreturn of the midgut to the peritoneal return of the midgut to the peritoneal cavity which usually occurs around cavity which usually occurs around thth 1010 kkthe the 10 10 week.week.

Umbilical cord hernia…cont

It is uncommon .It is uncommon .Small defect (less than Small defect (less than 2 2 cm) .cm) .Located at the umbilicus with the Located at the umbilicus with the umbilical cord extending from itumbilical cord extending from itumbilical cord extending from it.umbilical cord extending from it.Covered with a sac.Covered with a sac.Contains only the midgut . Contains only the midgut .


These patients might have ese pat e ts g t a emalrotation , although it is not

ll f i i lusually a cause of intestinal obstructionobstruction.

( Michael D.Klein / Grosfeld etal. pediatric surgery sixith edition 1157-1171,2006)


W t bili l l & DWet umbilical cord

clamp. & sep. cord

Dryness

Normal Umbilical Cord

How to differentiate?How to differentiate?

Cogenital Abdominal wall defectsDefect site sac contents frequency Associated

anomaliesoutcome

Omphlocele (lat. Fold)

umbilicus yes Liver , intestine ,spleen, gonad

common Chromo. & cardiac

Good (dep. on the

associated anomaly)gonad anomaly)

Omphlocele (cephalic

Fold)

Sup. umbilicus

yes Liver, intestine

rare Cardiac,sternal cleft ,central

t d di h

poor

tendon diph.

Omphlocele (caudal Fold)

Inf. umbilicus yes intestine rare Bladder extophy,impe

rforated

fair

rforated anus&episp

Umbilical cord hernia

umbilicus yes intestine unusual uncommon good

Gastoschisis Rt. umbilicus No intestine common Intestinal atresia

good

Ectopia cordis

thoracis

Midline sternum

No heart rare cardiac poor


Management:Counseling and reassuring the parentsCareful examination to determine the

following:Diameter(<2cm)Diameter( 2cm)Status of the content

• Reducible• Reducible • Irreducible which might be due to adhesions

or membrane.


h f d dThe type of management depends upon:If the base is narrow & there is short protrusion f h d i f hof the contents Reduction of the contents

& Simple ligation of the sac .


If the base is Broad & there is long epithelialized protrusion around the umbilicusepithelialized protrusion around the umbilicus Initial reduction , clamping & immediate or later repair with cosmetic umbilicoplastyp p y


If the contents are not reducible or if there i bl di M d i lis bleeding Mandatory surgical intervention .


The contents are easily reduced by holding the sac upwards & gently milking the bowel into the peritoneal g pcavity.The fascia can always be closedThe fascia can always be closed primarily & a cosmetic umbilicoplasty is nea l al a s feasible hich mightis nearly always feasible which might be immediate or late (OR).

Different presentations:


Care should be taken as the content of the sac is the midgut with or without

AppendixAppendix.Patent omphalomesenteric duct.Adhesions between the bowel and the sac as it will be seen in one of ourthe sac as it will be seen in one of our cases.

(Catrena Borgna - pignatti etal. Journal of pediatric surgery,30:1717-1718,Des.1995)

(David M. sherer .Gynecol obstet Invest 51:66-68,2001)


The umbilical abnormality can be di d i h i f d lidiagnosed with certainty after delivery , but ,antenatal ultasonography , can be h l f l d hhelpful in determining these abnormalities such as

Hernia of the umbilical cord OmphaloceleOmphaloceleTeratoma of the cord.


This gives a indication forThis gives a indication for distal clamping of the cord to avoid injury of the bowel

til th b b i tt d d buntil the baby is attended by the pediatric surgeonthe pediatric surgeon.


In KAUH 14 cases of umbilical cord hernia seen & treated over the last 10years (1997-2007).y ( )Retrospective review of antenatal ultrasonography did not indicate theultrasonography did not indicate the presence of the abnormality.All of the cases were near term ranging between 34-38 weeks.


12 of which had reducible content while the other 2 cases presented by irreducibility due to adhesions in oneirreducibility due to adhesions in one of them and septum that prevent the reduction in the other one which led to hemorrhagic fluid upon trial ofled to hemorrhagic fluid upon trial of the reduction.


8 of the cases were managed by a simple d ti f th t t d li ti freduction of the contents and ligation of

the sac. (short neck ,narrow base)


4 f h h d id b &4 of the cases had wide base & long epithelialzed protrusion , were managed by repair of the umbilicalmanaged by repair of the umbilical hernia ( mayo s repair & cosmetic umbilicoplasty )

2 i di2 immediate .2 late closure.


2 cases needed immediate surgical intervention in the form of Repair & umbilicoplasty due to irreducibility which was due to:

AdhesionsAdhesions. The presence of septum.


Despite of that most of the patients p pwith hernia of the umbilical cord were having malrotation but thiswere having malrotation, but , this was not an indication to explore any of our patients.

( Grosfeld etal. pediatric surgery sixith edition 1157-1171,2006)


Conclusion:Hernia of the umbilical cord is a rare entity of the abdominal wall defects , y ,but , careful attention should be paid in order not to miss it.If there is any suspicion of an umbilical cord hernia , the umbilical clamp should , pbe applied distally to avoid injury of the contents.


Force should not be applied in pporder not to cause any damage to the bowel while reducing theto the bowel while reducing the contents, keeping in mind the possible causes of irreducibility.

suggest the presense of an umbilical mass , but other diffrentials can not be excludedbut, other diffrentials can not be excluded which might be an omphalocele , umbilical hernia with associated omphalomesenterichernia with associated omphalomesenteric duct (David M. sherer .Gynecol obstet Invest 51:66-68,2001) or an isolated patent51:66 68,2001) or an isolated patent omphalomesenteric duct (Jona JZ:congenital hernia of the cord and associated patent omphalomesenteric duct :a frequent neonatal problem ? Am J perinatol 1996;13:223-226.)


Differentiation from other abdominal wall fdefect should be kept in mind

umbilical hernia--- the defect is covered by a normal skin and is rarely present at birth , instead usually becoming apparent in the first weeks or months of life after the cord separation & epithelialization of the umbilical stump.


4 of the cases had wide base & long epithelialzed protrusion , were managed by repair of themanaged by repair of the umbilical hernia ( mayo s repair & cosmetic umbilicoplasty )

2 immediate2 immediate .2 late closure.


If the base is narrow & there is short protrusion ----------

d f hReduction of the contents & Simple l f hligation of the sac .


If the base is Broad & there is long epithelialized protrusion ------Initial reduction , lclamping &

immediate or later hrepair with cosmetic

umbilicoplasty

hernia of the umbilical cord [وضع التوافق] of the umbilical cord.pdf · umbilical cord...

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